CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME TALAGTAG
NAME EXTENSION (JR., SR) N/A
FIRST NAME HAZELL

MIDDLE NAME BONAGUA

3. DATE OF BIRTH
(mm/dd/yyyy) 12/26/1997 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by birth
naturalization
4. PLACE OF BIRTH PRIETO DIAZ,SORSOGON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female
Male ✘

17. RESIDENTIAL ADDRESS N/A N/A

6 CIVIL STATUS ✘ Single Married
House/Block/Lot No. Street
Widowed Separate
N/A QUIDOLOG
Other/s: d
Subdivision/Village Barangay
PRIETO DIAZ SORSOGON
7. HEIGHT (m) 1.61
City/Municipality Province
8. WEIGHT (kg) 54 ZIP CODE 4711

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE "O+"
House/Block/Lot No. Street
N/A QUIDOLOG
10. GSIS ID NO. 2005692638
Subdivision/Village Barangay
PRIETO DIAZ SORSOGON
11. PAG-IBIG ID NO. 121215301846
City/Municipality Province

12. PHILHEALTH NO. 102524598458 ZIP CODE 4711

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 495869175 20. MOBILE NO. 0950-336-4157

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) hazelltag2019@gmail.com

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A N/A
FIRST NAME N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME TALAGTAG

NAME EXTENSION (JR., SR) JR
FIRST NAME EDUARDO

MIDDLE NAME DECHAVEZ

25. MOTHER'S MAIDEN NAME

SURNAME BONAGUA

FIRST NAME HILDA

MIDDLE NAME DOMANAIS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLARSHIP/
26. NAME OF SCHOOL PERIOD OF ATTENDANCE YEAR
LEVEL (Write in BASIC EDUCATION/DEGREE/COURSE
(Write in full)
UNITS
GRADUATED
ACADEMIC
HONORS
full) EARNED
(if not graduated) RECEIVED
From To

ELEMENTARY QUIDOLOG ELEMENTARY SCHOOL ELEMENTARY GRADUATE 2003 2009 N/A 2009 N/A

SECONDARY PRIETO DIAZ NATIONAL HIGH SCHOOL HIGH SCHOOL GRADUATE 2009 2013 N/A 2013 N/A
VOCATIONAL /

ASEAN COLLEGE OF SCINCE AND TECHNOLOGY NATIONAL CERTIFICATE II 2013 2013 N/A 2013 N/A
TRADE
COURSE
COLLEGE SORSOGON COMMUNITY COLLEGE DIPLOMA IN MIDWIFERY 2014 2016 N/A 2016 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

RA 1080- BOARD OF MIDWIFERY 78.65% 11/05-06/2016 LEGAZPI CITY 0172538 12/26/2026

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
GOV'T
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To (Y/ N)

02/01/2024 12/31/2024 MIDWIFE II DEPARTMENT OF HEALTH 28,512.00 11-1 CONTRACTUAL Y

01/16/2023 12/31/2023 MIDWIFE II DEPARTMENT OF HEALTH 27,000.00 11-1 CONTRACTUAL Y

01/01/2022 12/31/2022 MIDWIFE II DEPARTMENT OF HEALTH 25,439.00 11-1 CONTRACTUAL Y

02/05/2021 12/31/2021 MIDWIFE II DEPARTMENT OF HEALTH 23,877.00 11-1 CONTRACTUAL Y

01/02/2020 12/31/2020 MIDWIFE II DEPARTMENT OF HEALTH 22,316.00 11-1 CONTRACTUAL Y

07/16/2019 12/31/2019 MIDWIFE II DEPARTMENT OF HEALTH 20,754.00 11-1 CONTRACTUAL Y

07/01/2019 07/15/2019 MIDWIFE II DEPARTMENT OF HEALTH 20,754.00 N/A CONTRACT OF N

SERVICE

01/15/2018 12/31/2018 MIDWIFE DEPARTMENT OF HEALTH 20,179.00 N/A CONTRACT OF N

SERVICE

05/15/2017 11/15/2017 GOVERNMENT INTERNSHIP PROGRAM DEPARTMENT OF LABOR AND EMPLOYMENT 4,300.00 N/A CONTRACTUAL N

02/01/2017 05/15/2017 MIDWIFE LOCAL GOVERNMENT UNIT OF PRIETO DIAZ 4,000.00 N/A JOB ORDER N

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)

INCLUSIVE DATES OF
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS
( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

VISIONING TOWARDS SUSTAINABILITY 10/30/2024 10/30/2024 8.0 TECHNICAL BALIK KALIPAY CENTER FOR PSYCHOSOCIAL
RESPONSE,INC.
HRH ENHANCEMENT SYMPOSIUM(ORIENTATION ON HEALTH PROMOTION FRAMEWORK 08/09/2024 08/09/2024 8.0 TECHNICAL DEPARTMENT OF HEALTH,BICOL CENTER FOR
STRATEGY AND SOCIAL AND BEHAVIORAL CHANGE COMMUNICATION) HEALTH DEVELOPMENT
NATIONAL TUBERCULOSIS CONTROL PROGRAM-MANUAL OF PROCEDURE 6TH 12/29/2023 12/29/2023 34.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY
EDITION

TRAINING MANAGEMENT FOR COVID19 VACCINE TRAINERS 03/26/2022 03/26/2022 4.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

MICROPLANNING 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

PROFILING AND DATA MANAGEMENT FOR COVID19 VACCINATION 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

SUPPLY CHAIN MANAGEMENT FOR COVID19 VACCINE 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

RISK COMMUNICATION AND COMMUNITY ENGAGEMENT (RCCE) ON COVID19 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY
VACCINATION

ADDRESSING THE PSYCHOLOGICAL BARRIERS TO VACCINATION 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

VACCINE ADMINISTRATION 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

MANAGING ADVERSE EVENTS FOLLOWING COVID19 IMMUNIZATION (AEFI) 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

IMMUNIZATION WASTE MANAGEMENT 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

INFECTION PREVENTION AND CONTROL FOR COVID19 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

VACCINE DEMAND GENERATION AND RISK COMMUNICATIONS 03/24/2022 03/24/2022 2.0 TECHNICAL DEPARTMENT OF HEALTH ACADEMY

STRENGTHENING COMMUNITY ACTION AGAINST COVID-19 VARIANTS 08/20/2021 08/20/2021 4.0 TECHNICAL DEPARTMENT OF HEALTH,BICOL CENTER FOR
HEALTH DEVELOPMENT
STEPPING UP CHILDHOOD TB CARE AND PREVENTIONS: BEST PRACTICES,NEW TOOLS 08/11/2021 08/11/2021 2.0 TECHNICAL THE PHILIPPINE COALITION AGAINST
AND GUIDELINES TUBERCULOSIS

SUICIDE FIRST AID 04/16/2021 04/16/2021 8.0 TECHNICAL LOCAL GOVERNMENT UNIT OF PILAR

REGIONWIDE CRASH COURSE ON BASIC EXPANDED IMMUNIZATION PROGRAM(EPI) 03/09/2021 03/09/2021 8.0 TECHNICAL DEPARTMENT OF HEALTH,BICOL CENTER FOR
FOR COVID-19 VACCINATION ROLLOUT HEALTH DEVELOPMENT

COLD CHAIN,LOGISTICS AND WASTE MANAGEMENT FOLLOW-UP TRAINING 02/22/2021 02/22/2021 8.0 TECHNICAL DEPARTMENT OF HEALTH,BICOL CENTER FOR
HEALTH DEVELOPMENT

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. NON-ACADEMIC DISTINCTIONS / RECOGNITION (Write in full) 33. (Write in
full)

INTEGRATED MIDWIVES ASSOCIATION OF THE

COMPUTER LITERATE N/A PHILIPPINES

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree?
YES ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

If YES, give details:

________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
YES ✘ NO
If YES, give details:
________________________________
________________________________

b. Have you been criminally charged before any court? YES ✘ NO

If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
by any court or tribunal? YES ✘ NO
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased YES ✘ NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
election to promote/actively campaign for a national or local candidate?
If YES, give details:

39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA
7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:
a. Are you a member of any indigenous group?
YES ✘ NO
If YES, please specify:
b. Are you a person with disability?
YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent?
YES ✘ NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
DAVID R. DAZA PILAR,SORSOGON 09321079522 3.5 cm. X 4.5 cm
(passport size)

BRIAN WALDO A. FLORES DONSOL,SORSOGON 09295692642 With full and handwritten

name tag and signature over
printed name
BENITO L. DOMA PRIETO DIAZ,SORSOGON 09196185258
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of
administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance

Government Issued ID: PRC ID

ID/License/Passport No.: 0172538

Signature (Sign inside the box)

Date/Place of Issuance:
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4

 Attachment to CS Form No. 212

WORK EXPERIENCE SHEET

Instructions: 1. Include only the work experiences relevant to the position being applied to.

2. The duration should include start and finish dates, if known, month in abbreviated form,
if known, and year in full. For the current position, use the word Present, e.g., 1998-
Present. Work experience should be listed from most recent first.
Sample: If applying to Supervising Administrative Officer
• Duration:
• Position:
• Name of Office/Unit:
• Immediate Supervisor:
• Name of Agency/Organization and Location:

• List of Accomplishments and Contributions (if any)

o
o
o

• Summary of Actual Duties

o
o
o
o
o

• Duration:
• Position:
• Name of Office/Unit:
• Immediate Supervisor:
• Name of Agency/Organization and Location:

• List of Accomplishments and Contributions (if any)

o
o
o

• Summary of Actual Duties

o
o
o
o
o

• Duration:
• Position:
• Name of Office/Unit:
• Immediate Supervisor:
• Name of Agency/Organization and Location:

• List of Accomplishments and Contributions (if any)

o
o
o
• Summary of Actual Duties
o
o
o
o
o

JUAN A. DE LA CRUZ
(Signature over Printed Name
of Employee/Applicant)
Date: